C A LIFORNIA HEALTHCARE FOUNDATION

How Smartphones Are Changing Health Care for Consumers and Providers

April 2010 How Smartphones Are Changing Health Care for Consumers and Providers

Prepared for California He a l t h Ca r e Fo u n d a t i o n by Jane Sarasohn-Kahn, M.A., M.H.S.A.

April 2010 About the Author Jane Sarasohn-Kahn, M.A., M.H.S.A., is a principal with THINK- Health and writes the Health Populi blog.

Note: Inclusion of products and vendors in this report does not constitute an endorsement or recommendation.

Acknowledgments The author expresses special thanks to the experts who provided counsel, data, and insights that are incorporated into this report: Meredith Abreu-Ressi, Manhattan Research; Andre Blackman, Pulse + Signal; Ed Daniels, Point-of-Care Partners; Scott Eising, Mayo Clinic; Dr. B.J. Fogg, Stanford, Persuasive Technology Lab; Susannah Fox, Pew Internet & American Life Project; Katy Hartley, Phillips Center for Healthy Living; Rob Havasy, Center for Connected Health; Raj Kapoor, Advance Wellness Institute; Dr, Joseph Kim, Physician and Technologist, Medical Smartphones blog; David Krajicek, GfK; Monique Levy, Manhattan Research; Joy Liuzzo, Insight Express; Julie Murchinson, Health 2.0 Accelerator; David Sanderson, MedApps; Brett Shamosh, WellApps; Juhan Sonin, MIT; Jonathan Woodbridge, UCLA; and Marion Zabinski, Myca. Two generous peer reviewers have added valuable input into the paper: Dr. Ted Eytan, The Permanente Federation, LLC; and Brian Dolan, MobiHealthNews.

About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org.

©2010 California HealthCare Foundation Contents

2 I.  Smartphones Meet Health and Health Care

5 II.  Who Are the Consumers of Mobile Internet?

8 III.  Smartphone Apps for Clinicians and Consumers Medical Reference Tools Diagnostic Tools Continuing Medical Education Patient Records — EHRs and PHRs Patient and Health Consumer Support

13 IV. The Market for Smartphones and Health: Some Barriers

17 V. Looking Forward: Insights from the Early Adoption Phase

19 Endnotes I. Smartphones Meet Health and Health Care

The new wellness delivery channel Th e t o p i c o f s m a r t p h o n e s in h e a l t h is a n i n t e r s e c t i o n of two fast-evolving ecosystems: health and technology. The junction for ubiquitous care will be the is a dynamic one in which a particular communications platform is smartphone, and it will happen advancing both consumers’ and providers’ engagement with health information technology. sooner than you think. The speed of the uptake has been remarkable for a nation that has — John Mattison, M.D. Kaiser Permanente been traditionally slow to adopt HIT, as Figure 1 shows. Two-thirds of physicians used smartphones in 2009. About 6 percent of these were using a fully functional electronic medical record or electronic health record system — while only 1.5 percent of hospitals had a comprehensive electronic health record system as of 2008.1 On the consumer side, 42 percent of Americans owned smartphones as of December 2009, despite the recession that began a year earlier.2 In fact, according to cnet, the smartphone market was “unfazed by the recession.”3 What is it about the smartphone that makes it so attractive to consumers and providers of health care? 4 Unlike any other HIT platform, the smartphone is basically an inexpensive handheld

Figure 1. Consumer Smartphone Ownership, October 2006 to December 2009

45% 42%

40%

35%

30%

25%

20% 15% 15%

10%

5%

0% Oct Jan Apr Jul Oct Jan Mar Jun Sep Dec Mar Jun Sep Dec ’06 ’07 ’07 ’07 ’07 ’08 ’08 ’08 ’08 ’08 ’09 ’09 ’09 ’09

Source: “New Survey Shows Android OS Roiling the Smart Phone Market,” ChangeWave Research, January 2010.

2 | California He a l t h Ca r e Fo u n d a t i o n computer that enables users to accomplish tasks anywhere, anytime. It is so intuitive and user-friendly Smart and Smarter that most people can download and use the many In the absence of an industry-wide definition of “smartphone,” the boundaries between types available applications — or apps — without any of phones are blurring. Here are some general training or special knowledge about computers. understandings:

For clinicians, the smartphone offers an • Cell phones/mobile phones run over wireless alternative to many health IT formats that have communication networks through radio waves or been cumbersome and costly to adopt, and that satellite transmissions. All cell phones provide voice may interrupt their workflow. As of February communications and texting via Short Message Service, or SMS. 2010, there were 5,805 health, medical, and fitness • Feature phone or full-feature phones have applications within the Apple AppStore. Of these, additional functions such as a camera, mp3 player, 73 percent were intended for use by consumer or or downloadable games that are available through patient end-users, while 27 percent were targeted the wireless provider. to health care professionals. It should be noted • PDA phones or personal digital assistants that, although developers usually have a principal combine cell phone, Web browsing, and organizer audience in mind, all users can and do download functions such as calendars. the apps.5 In the “medical” category, 33 percent of • Smartphones run on a specific operating system (OS) and allow download of apps that run on the apps are meant for consumers/patients, 32 percent OS. Major operating systems include iPhone OS, for physicians, 17 percent for medical students, BlackBerry OS, Windows Mobile, PalmOS, WebOS, 4 percent for other health professionals, and Symbian, and all types of Linux including Android. 2 percent for nurses (10 percent were miscategorized by MobiHealthNews’ definition).

Figure 2. Medical iPhone Apps Geared to Consumers, Physicians, Medical Students, 2010

Other 12%

Miscategorized CME (1%) 12% Medical Medication Adherance (1%) Reference Emergency Information (2%) 50% Chronic Disease (3%) Prenatal and Infant Care (3%)

EMR and Operations (7%) Calculator 9%

Source: “The World of Health and Medical Apps,” MobiHealthNews 2010 Report, February 2010.

How Smartphones Are Changing Health Care for Consumers and Providers | 3 Within “medical reference apps,” the largest mobile health consumer, we found that people are category is medical student study guides (19 percent), looking for very action-oriented information. They followed by clinical consult (9 percent), anatomy are not necessarily going to do in-depth research (7 percent), and drug reference (7 percent). Within via mobile. If that’s the case, they will take content the consumer-focused health and fitness apps, the directly from the Web site. So we’re asking: How do most popular category is cardio exercise (15 percent), we create applications for the mobile form factor and followed by stress management (12 percent), diet platform, and provide action-oriented information?” (11 percent), and strength training (6 percent). See For those providers already connecting with Figures 2 and 3. patients through electronic health records and While Apple and the iPhone are the leading personal health records, the stage is set for mobile source of health and medical apps for smartphones health, whether on smartphone or feature phone. in 2010, more apps are being developed for other Kaiser Permanente’s personal health record, My operating systems that have or plan to serve both Health Manager, has a user base of over 3 million health consumers and physicians. enrollees. It would be a relatively easy transition to In 2010, most health consumers regularly seek morph over to mobile phones. health information online through trusted portals Kaiser can capitalize on its investment in such as Mayoclinic.com, which has provided health electronic health records and personal health content online since 1995 to “empower people to records — EHRs/PHRs — and develop mobile apps manage their health.” Mayo has now gone mobile. to serve patients managing chronic conditions as well “We’re a very content-oriented organization,” said as help healthy enrollees stay that way. Scott Eising of Mayo Clinic. “In our research into the

Figure 3. Medical Reference iPhone Apps, 2010

Student Other Study Guides Dentist (1%) 21% 19% Reference Codes (1%)

Radiology (1%) Clinical Consult Veterinarian (2%) 10% Swine Flu/H1N1 (2%) Nurse (3%) Anatomy 7% Medical Dictionary (4%)

General Patient (4%) Drug Reference (7%) Home Remedies (5%) Literature (6%) Emergency Care (5%)

Source: “The World of Health and Medical Apps,” MobiHealthNews 2010 Report, February 2010.

4 | California He a l t h Ca r e Fo u n d a t i o n II. Who Are the Consumers of Mobile Internet?

Sm a r t p h o n e s a r e t a k i n g a p r o m i n e n t SMS (text messaging) as they were to make voice place among the mobile phones that are used to calls from their mobile phone.7 reach the Internet. Eighty percent of Americans had a cell phone, a PDA phone, or a smartphone as of The Marrying Kind December 2009, and one-third of people have used a In Texting for Health, B.J. Fogg of Stanford Persuasive cell phone or smartphone to access the Internet. The Technology Lab observed: “In some ways, we don’t number of mobile Internet users increased 74 percent merely adopt mobile devices; we marry them. We between 2007 and 2009.6 See Figure 4. usually spend more time with our mobile phones than with our spouses or partners…. The best interactions in a marriage will create feelings of trust, competence, Figure 4. Internet Use on a Mobile Device, 2007 vs. 2009 and delight.”

• Yesterday • Ever A consumer segment named techfluentials has 32% been identified by the market research firm GfK. “Techfluentials see technologies as extensions 24% of themselves, especially in today’s social media environment,” David Krajicek of GfK explained. 19% “These individuals see those tools as coming to be parts of their lives. Over time, techfluentials will be 11% the next wave of individuals that will become more focused on health as issues and problems arise. They will turn to the tools they’re using in other parts of 2007 2009

Source: Wireless Internet Use, Pew Internet & American Life Project, July 2009. their lives” to manage their health, said Krajicek. While accessing the Internet via stationary computers is stratified by socioeconomic status, Research by Wells Fargo, the financial services mobile search is not. African Americans are the most company, found that the “most digital” age cohort active users of the mobile Internet — and their use of is people in their thirties. And while the bulk of it is also growing the fastest. This means the digital younger people have integrated online and mobile divide diminishes when mobile use is taken into technologies into their daily lives, older people are account. See Figure 5 on the following page. doing so as well. Although 59 percent of adults Twenty-nine percent of African Americans over 70 responded that they do not use any online use the Internet on their handheld on an average entertainment technologies — that means that day, significantly greater than the national average 41 percent do. Furthermore, 60 percent of people of 19 percent.8 Looking across a range of digital age 45 and over were found to be just as likely to use activities (some done online using a computer and

How Smartphones Are Changing Health Care for Consumers and Providers | 5 Figure 5. Americans Accessing Internet by Tethered Table 1. Wireless Internet Use, or Cell Phone Means, by Race, 2009 by Selected Characteristics, 2009

% of Total Total Adults 55% 94% Men 59% 91% 87% Women 51%

Race/Ethnicity White 52%

African American 59%

Hispanic 62%

Age Group 18 to 29 80%

30 to 49 66%

White African American Hispanic 50 to 64 42%

Source: Wireless Internet Use, Pew Internet & American Life Project, July 2009. 65+ 16%

Annual Household Income Less than $30,000 46%

others on a mobile device) African Americans and $30,000 to $49,999 55% Whites, on average, have the same level of usage. $50,000 to $74,999 61% The high level of activity among African $75,000 and higher 76% Americans on mobile devices helps offset lower levels Educational Attainment of access to tools that have been traditional onramps Less than high school 41% to the Internet — desktop computers, laptops, and High school 42% home broadband connections. Still, there remain disparities between mobile users of the Internet and Some college 63% those who have tethered access. People in rural areas, College and higher 69% as well as those who have less education or are over Community Type age 65, are less likely to have wireless Internet access. Urban 57% See Table 1. Suburban 56% Rural 45%

Source: Internet User Profiles Reloaded, Pew Internet & American Life Project, January 2010.

6 | California He a l t h Ca r e Fo u n d a t i o n Mobile health was named by Gartner as one of However, there is still a gap between the promise its top ten consumer mobile applications for 2012. and the reality for health consumers who are ill. Mobile health monitoring could help payers, both As the chart illustrates, people with two or more private and public, to reduce costs related to chronic chronic conditions are least likely to go online, have diseases and improve patients’ quality of life. Gartner broadband at home, or receive text messages. See sees that the industry will be able to monetize Figure 6. mobile health services by offering mobile health care The opportunity here for developers is that monitoring products, services, and solutions to care 70 percent of people with two or more chronic delivery organizations.9 conditions have a cell phone.

Figure 6. Technology Use by People with Chronic Conditions, 2008

Go online 81% 68% 52%

Dial-up at home 12% • No Condition 16% • 1 Condition 15% • 2+ Conditions

Broadband at home 61% 45% 37%

Wireless access 50% 31% 24%

Have a cell phone 89% 76% 70%

Get all or almost all calls on cell phone 21% 9% 11%

Send/receive text messages 60% 32% 23%

Source: Chronic Disease and the Internet, Pew Internet & American Life Project, March 2010.

How Smartphones Are Changing Health Care for Consumers and Providers | 7 III. Smartphone Apps for Clinicians and Consumers

Acc o r d i n g t o Ma n h a t t a n Re s e a r ch , “Many doctors are behind the times in practicing the number of physicians who own smartphones will medicine. They’re applying old guidelines to care,” increase from 64 percent in 2009 to 81 percent by said Dr. Kim. The best way to keep up to date is not 2012. An Epocrates survey of its users — published by attending a symposium once a year or checking ten days after Apple’s announcement of the iPad in emails, he said. “If you give clinicians the right tools February 2010 — found that one in five physicians and the right information at the right time, it will said they were likely to purchase an iPad.10 improve the way they treat patients.” An example Some of the most widely used mobile applications is FDA Recalls, a free app on iTunes that provides by physicians are drug and clinical references, and information about recalled products. clinical tools such as dosage calculators.11 Monique Medical Reference. Because clinical care is Levy, senior director of research for Manhattan information-intensive, it is natural for health Research, said she is seeing the line between the tasks information to go mobile as clinicians make decisions done by physicians on desktop computers and on at the point of care. Among the most mature mobile mobile devices “start to blur.” Transaction-oriented reference sources developed for smartphones is point-of-care apps, such as electronic prescribing Epocrates, an online medical reference company and evidence-based decision support, are the next that celebrated its 10th anniversary in 2009. growing category for physicians’ smartphones. Epocrates offers mobile platforms for the major Following are a few examples of health and operating systems including Android, Blackberry, medical app categories. The actual market includes iPhone, Palm, and Win Mobile. More than many more, and is growing rapidly. 125,000 physicians use Epocrates’ products on iPhone and iPod touch devices, alone. The first Medical Reference Tools medical application for the iPhone, Epocrates’ Alerts and Awareness. Dr. Joseph Kim, physician drug reference, is the most popular free medical technology blogger at Medical Smart Phones, sees download in the iTunes store. A study at Brigham & opportunities for helping physicians stay abreast Women’s Hospital in Boston found that 60 percent of clinical information. “Everyone has a spare five of Epocrates users reported avoiding three or more minutes in the day,” he said. “The question is, are medical errors a month.12 The company’s own time- doctors using their smartphones to stay current on study found that doctors who use the reference tool breakthroughs and FDA alerts?” Smartphones can be save at least 20 minutes a day in pharmacy call-backs networked into alert systems via Twitter and other and real-time mobile information search while in the platforms. The FDA or CDC could issue alerts to exam room. virtually every health provider via the clinician’s Another major medical reference firm, Skyscape, handheld, setting off an alarm. Clinical advice, works with more than 50 health publishers and has guidelines, and news on the latest breakthroughs assembled the largest library of medical resources could be communicated this way in five-minute bits. available for every smartphone operating system.

8 | California He a l t h Ca r e Fo u n d a t i o n Anatomy references include Netter’s Anatomy results and providing diagnostic support. Current app, which is based on the popular Atlas of Human popular lab apps include ARUP Consult and Anatomy. The Medical Encyclopedia by University of Care360. Maryland Medical System was one of the ten most Digital imaging. The OsiriX app can be popular free apps in the iTunes Store in December thought of as a mobile PACS (picture archiving 2009. communications system) for the smartphone. At the Like physicians, consumers also access medical 2009 annual meeting of the Radiological Society of reference information via mobile devices. The Evincii North America (RSNA), several papers demonstrated app helps consumers look for over-the-counter the efficacy of using smartphones in digital imaging medication for particular symptoms. This app grew applications.15 ERoentgen Radiology Dx is an app out of a service once available via a kiosk in retail that helps radiologists identify the most appropriate pharmacies. There are also many symptom checkers radiology exam for a patient. available for consumers; in 2010, the Mayo Clinic ECG. There are many electrocardiogram apps began to offer the Symptom Checker iPhone app that offer images of the most common ECG results. in February 2010, similar to the hospital’s online Instant ECG (one of the top ten paid iPhone apps in version. December 2009), ECG Guide, and ECG Interpreter are among the most used. Diagnostic Tools Emergency department. Mobile health solutions General diagnosis. One of the most popular apps on smartphones are designed to increase productivity for doing differential diagnosis is Diagnosaurus, in busy ERs. Physicians use the Vigilance app to written by Dr. Roni Zeiger (currently affiliated track patients’ vital signs, transmit live videos from with Google Health). The IDdx is an app covering exam and operating rooms, and receive alerts when infectious disease diagnosis, based on Control of patients are in distress so doctors can respond even Communicable Disease Manual. Some diagnostic before nurses page them. apps target specific conditions: STAR Analytical Obstetrics. AirStrip OB is an iPhone app that Services developed an app that analyzes coughs.13 provides obstetricians real-time, remote access to fetal The company received a grant to create the app for heart tracings, contraction patterns, nursing notes, developing countries. Star’s Suzanne Smith noted and vital signs. Obstetricians can monitor different that coughs are “the most common symptom when stages of labor even when they are not by a patient’s a patient presents, and we are relying on doctors side. This increases the OB’s ongoing interaction and nurses with good old technology from the 19th with the labor and delivery department and gives the century.”14 doctor real-time data. Lab apps. Smartphones can deliver physicians’ Remote physician consultation. Remote laboratory and blood work results as soon as they physician consults via desktop computers have are completed. This just-in-time reporting can help emerged through services like American Well, Myca physicians and patients avoid phone tag. If a value Health, RelayHealth, and TelaDoc. They have is abnormal, the physician can immediately email gained traction in the market as reimbursement is a patient follow up instructions. The lab app will negotiated between payer, provider, and patient. evolve next to assist clinicians in interpreting lab As this alignment of incentives continues, remote

How Smartphones Are Changing Health Care for Consumers and Providers | 9 consults will migrate to various devices beyond the MacPractice MD, motionPHR, NextGen, Ringful, desktop computer and, over time, onto smartphones. and Webahn. Qualcomm has 12,000 employees in the San Diego This list will grow “exponentially,” according to area. The company operates a corporate health center Dr. Joseph Kim, who says, “we’ll see a huge change and is creating “the clinic without walls,” which uses in the next couple of years. But will physicians know the Myca platform for managing communications how to use these systems effectively? There isn’t much between the care team and the employee. Many robust clinical decision support backed by evidence- Qualcomm workers travel outside of San Diego; based medicine yet” for these applications. Myca enables remote consultations between health With the implementation of the American center staff and mobile employees via mobile devices Recovery & Reinvestment Act of 2009 (ARRA), like smartphones, which enhances the company’s stimulus funding will be distributed to health ability to extend wellness beyond the company’s providers who implement electronic health records physical doors. As Dr. Marion Zabinski of Myca (EHRs) according to “meaningful use” criteria. explained, “people are so connected to phones, Mobile EHRs could open up physician access to they’re an extension of themselves. You can’t have patients if the apps have the same security layers as your doctor with you all the time but the phone their desktop counterparts. Then physicians could can keep you on the right path toward health and communicate with patients from anywhere, and not wellness.” be tethered to the desktop application. “This could change physician access electronically from 24 hours Continuing Medical Education to 24 seconds,” predicted Dr. Ted Eytan of The The Internet is playing a growing role in continuing Permanente Federation. medical education (CME).16 Several services provide As consumers get more engaged in tracking their CME credits using smartphones, including Epocrates health information, personal health records (PHRs) Mobile CME, MedPageToday, QuantiaMD, will gain adoption. Four in five U.S. adults believe ReachMD, Skyscape CME STAT, and UpToDate. that online PHRs would be beneficial in managing Wolters Kluwer Health, the medical publisher, their health and health care. Nearly one-half of developed the XtraCredit app that provides CME Americans are interested in using an online PHR credit for clinical research done online. CME via service.17 However, PHR adoption remains very low; smartphones will grow in adoption as mobile Web only 3 percent of U.S. adults had a PHR in 2008. If browsers accommodate more multimedia formats meaningful use criteria under ARRA include patient- such as Flash. engagement, then PHR adoption should grow. The PHR supply side is populated with about Patient Records — EHRs and PHRs 20 Internet-based PHRs on the market as of This crowded market segment is attracting new February 2010.18 PHRs can be stand-alone (where entrants who are innovating “lighter” open health data are populated by the consumer), tethered source solutions, including records apps for to an EMR system (controlled by physicians), smartphones. Several currently offer smartphone or non-tethered (Internet-based PHRs largely capability, including Allscripts, CareTools iChart, controlled by consumers). Because smartphones are eClinicalWorks, EPIC’s Haiku, LifeRecord, extensions of users’ personal lives, they could make

10 | California He a l t h Ca r e Fo u n d a t i o n useful platforms for personal health records that are among patients with chronic conditions may be as managed by consumers themselves. low as 20 percent.19, 20 Many factors are involved, A handful of PHRs are available via smartphone. including cost/affordability, ineffective patient/ Polka works on the iPhone; it stores and analyzes the provider interaction, lack of patients’ understanding consumer’s personal health data, and offers health their disease, complex treatment plans, side effects, reminders. Aetna connects enrollees’ smartphone confusion and forgetfulness, and language barriers.21 apps to a PHR. The ICE app was developed by Technology can play an important role in Legalzoom and Donate Life America to store users’ supporting people to adopt and stick with prescribed personal information that can be accessed by first treatments. Medication Tracker, MedsLog and responders (e.g., paramedics, firefighters, and ER Pillbox are among the more popular medication workers) “in case of emergency.” In addition to trackers in the iPhone store. The Pillboxer Lite app this app, there are several other emergency apps tracks medications, vitamins, and supplements with a incorporating the “ICE” acronym in their names. graphic interface that resembles the “Sunday through Saturday” pillbox format. The Pill app can remind Patient and Health Consumer Support women to take their birth control meds. Inhaler Scott Eising of the Mayo Clinic said, “Part of our Tracker helps asthma sufferers track and record vision for Mayo is that it’s not only a destination inhaler use. medical center. We are going to take care of patients The HIV/AIDS Red Ribbon Health Manager here and ‘there,’ whether at home or at work.” app generates medication reminders via both email Patients managing chronic conditions and healthy and text. Users can opt for one or both. The app consumers who want to keep well can be served in a incorporates Observations of Daily Living (ODLs), variety of ways. Mayo Clinic launched its first iPhone which enable users to track aspects of their lives that app, Mayo Clinic Meditation, in December 2009. are germane to their conditions. The clinic followed up this app in February 2010 For multiple sclerosis, i-inject is an app available with the free Symptom Checker, based on its popular for iPhone that sets medication reminders, tracks online version. rotation of injection sites, runs medication reports, Some apps focus on a single illness. Brett and enables emailing to physicians. Shamosh, who has ulcerative colitis (UC), created Mobile and home monitoring. A number an iPhone app to help fellow patients deal with the of apps connect patients with chronic conditions condition. “We developed the software to cater to to clinicians, caregivers, and health coaches on a you and your personal condition. If you’re willing continuous basis. Sensor technologies combined with to talk to us, you have to be incentivized, even mobile communications can be used to track various inspired, to work with us,” Shamosh has learned. As health measurements for patients or loved ones. he receives feedback on his GI Monitor app from Among a long list of sensors that can be incorporated users, he continues to add user-defined value to the into smartphones and used for health monitoring are: application. ◾◾ Accelerometers that register different motions Medication adherence and compliance. and walking “gait”; Studies on patient adherence to prescribed drug regimens have demonstrated that compliance

How Smartphones Are Changing Health Care for Consumers and Providers | 11 ◾◾ Infrared photo-detectors that measure body wellness, fitness, and nutrition. Examples are: The temperature, heat flux and heart rate; and Carrot, Eat This/Not That (based on the popular diet book), SparkPeople, and WebMD Mobile (with over ◾◾ Glucometers to measure blood glucose. 1 million iPhone downloads in 2009). Other wellness apps are focused on complementary and alternative People with diabetes have access to a large array medicine, such as those offering support for sleep and of mobile monitoring devices, some of which are meditation like the Mayo Clinic offering. available through smartphones. Roche Diabetes Care, Managing conditions. A highly activated group the maker of Accu-Chek blood glucose meters and of health consumers has adopted mobile devices insulin delivery systems, partners with Mylestone to help manage chronic conditions. In early 2010, Health’s Glucose Buddy, which integrates with apps were available for the most common chronic Roche’s iPhone app. The app calculates the impact of conditions including (alphabetically) anorexia, the user’s meals, activities, and other actions on blood asthma, cancers, chronic obstructive pulmonary glucose levels. disease, Crohn’s disease, diabetes, glaucoma, heart MedApps began as a smartphone-based disease, HIV/AIDS, hypertension, migraine, and monitoring application. However, given the relatively multiple sclerosis, among other diseases. Most small user-base of smartphones in target populations disease-specific apps in the iTunes Store are aimed (chronically ill people, seniors), the company at clinicians as “medical apps,” although they can be subsequently re-engineered its offering in the form downloaded by anyone. of a wireless handheld device, the HealthPAL. This Ed Daniels, an expert on point-of-care device looks like a wireless phone, but operates technology, defines “symptom-driven” health apps as differently. Patients managing chronic conditions those where navigation is controlled by user-entered do their regular monitoring through their usual medical information, and where the application may devices including blood pressure cuffs, glucometers, be programmed to use that data to record patient spirometers, pulse oximeters, and weight scales. The symptoms over time, to recommend treatments, or Bluetooth-enabled HealthPAL device communicates to connect the user with services, physicians, and the user’s health data to providers for their hospitals. monitoring, review, and reporting. The data can Caregivers of children or aging parents might also be routed to a health record repository such as find smartphones useful for streamlining complicated Microsoft HealthVault or Google. and/or long-distance care for their loved ones. In a Home care. Nearly 40 percent of home health survey of parents of children with diabetes conducted agencies use some kind of point-of-care system in the by the Center for Connected Health, most expressed field. Use of handhelds for home health is expected interest in enrolling in a mobile phone glucometer to have significant growth. One in every three service, with two-thirds of parents feeling very home care managers uses a smartphone. Most use a positive about a proposed prototype. According BlackBerry, with 50 percent of the market, followed to the researchers, “enthusiasm decreased with by iPhone (15 percent), Microsoft (15 percent), and increasing annual service cost.”23 Palm Treo (6 percent).22 Wellness and fitness apps. Many hundreds of smartphone apps for health consumers focus on

12 | California He a l t h Ca r e Fo u n d a t i o n IV. The Market for Smartphones and Health: Some Barriers

Acc o r d i n g t o a Pr i c e w a t e r h o u s e Co o p e r s Where is the patient in the app? Too much survey, one-half of U.S. health consumers are willing app development is done by technologists, to engage in online care and consultation with seemingly without much user input. “In an hour- clinicians over a phone. Only one-quarter prefer to long presentation by a major telecoms company stick with the traditional delivery model (Figure 7). at an mHealth conference, the word ‘patient’ was Some market forces foster adoption of mobile not mentioned once,” observed Rob Havasy of the health technologies, and in particular smartphones; Center for Connected Health. In general, enterprise however, several key barriers will slow the progress of developers see more potential for profits in hospitals adoption. and physicians and not in the consumer segment. As health apps proliferate in this early phase Figure 7. Consumers Willing to Use Alternative of mobile health, “Too many health smartphone Methods to Get Care, 2009 apps are ill-conceived,” observed B.J. Fogg, director of Stanford’s Persuasive Computer Lab, who has • Likely • Neither • Unlikely studied the role of technology in changing people’s health behaviors. “They’re not going to change Mobile device (text) anybody’s behavior,” he said. Fogg’s advice is to 21% 23% 55% “Put hot triggers in the path of motivated people.” Patient-group medical appointment Smartphone apps can do this very well — if properly 28% 29% 43% designed and targeted to those people who truly Retail clinic 36% 29% 34% want to engage in their health. It should be noted

Worksite clinic that apps for people who are sick need to be 37% 27% 36% appropriately designed in order to be accepted in the

Clinical trail/research already complicated lives of these patients and their 46% 27% 26% caregivers. Telephone consultation Driving the app economy. The payment 50% 27% 22% system and health stakeholder financing drive Internet or other computer technology much of the app economy. The result is that some 50% 24% 26% app categories are well populated while others are not. Conditions that are associated with products Note: Segments may not add up to 100 percent due to rounding. Source: Top 10 Health Industry Issues in 2010: Squeezing the Juice Out of Healthcare, such as pharmaceuticals, medical devices, and PricewaterhouseCoopers, December 2009. health plans — like diabetes — have the most apps. Some are the creations of companies that stand to gain from patients’ use of their products. An app created by a drug company could benefit the company, prescribers, and patients; for example, a

How Smartphones Are Changing Health Care for Consumers and Providers | 13 dosage calculator that applies only to a specific drug devices” under the FDA’s definition, although prescribed for the patient could be useful. Whatever they are not currently regulated by the agency. entity sponsors the development of a health app, the However, when smartphones connect to sensors sponsorship should be transparent to the end user. and automatically collect patient data, the FDA Shop till you drop. How can consumers may take on a regulatory role. In January 2010, the efficiently locate a health app that will be useful to FDA advised software developer MIMvista that its them? “Discoverability is a big issue,” asserted Brian imaging app for the iPhone would need to undergo Dolan of MobiHealthNews. “It’s overwhelming to pre-market approval to gain marketing clearance. enter an apps store and start a search.” The process This requires clinical trials, a process that is time- by which consumers seek health apps is cumbersome. consuming and expensive. “If software is intended Most of the health/fitness apps in the iTunes Store to provide cure, mitigation, treatment, or prevention have relatively few reviews on which a consumer can of disease, then the FDA may consider it a medical make an educated purchasing decision. “I haven’t device,” according to Ed Daniels of Point-of-Care seen a lot of user communities focused on apps yet,” Partners. The “wild west” nature of the health apps Dolan said. “This is also true on the clinician side.” store may be a recipe for FDA regulation toward the Further, it is difficult to ascertain whether a particular objective of protecting consumer safety. “The FDA app is new or an update incorporating learnings from may want to make an example out of one or two users and more robust functionality. apps to remind everyone that the agency is paying Caveat emptor, health app downloader. It is attention to health apps. ‘First, do no harm’ applies,” difficult to distinguish the safe, medically credible said Daniels. apps from the less-safe ones. “Anyone can create an Advertising as a business model. Presumably app and put it in an app store, warned Dr. Joseph to protect its turf in the mobile ad space, Apple Kim. “This is concerning.” He indicated that apps posted information on its iPhone developer Web site with branded logos from a government agency (e.g., alerting developers about incorporating location- CDC, FDA, or NIH) or academic institution (with based information (such as GPS) into apps. Apple Mayo Clinic, Cleveland Clinic, Johns Hopkins, and warned that if such location-based information were, the University of Maryland among the most active “to enable mobile advertisers to deliver targeted ads health app sponsors) are some of the most credible based on a user’s location,” the app would not be apps for consumers to download for personal use. accepted by the iTunes Store. Downloading an app doesn’t make you a Size and wiring matter. Mobile health solutions doctor. Consumers who are very technology-savvy will help providers and institutions manage care in may choose to download medical apps developed for lower-cost settings, and extend scarce resources from health professionals. These consumers may believe expensive digital imaging hardware to expert clinical that the downloading and use of medical apps is a specialists and visiting nurses. Larger institutions that replacement for consulting a physician. However, are well staffed and use electronic medical records there is a difference between participatory health and will be in a good position to adopt mobile health practicing medicine. tools. But, “even we struggle,” acknowledged Rob The looming presence of the FDA. It is not Havasy of the Center for Connected Health, part clear whether health and medical apps are “medical of the large Partners Health System in Boston. “For

14 | California He a l t h Ca r e Fo u n d a t i o n smaller hospitals, it will be that much harder when Figure 8. Medical Students Who Own Mobile Device, their staffs aren’t as used to using EMRs and CPOE.” by Brand, 2009 Physician practice workflow. With the advent of HIT stimulus money incentivizing hospitals iPhone/iPod Touch and providers to adopt EHRs, physician practices 45% will become more digitized. The biggest challenge Palm PDA 15% 29% 43 % to physicians, according to Dr. Joseph Kim, will Palm Smartphone be, “How will smartphones get integrated into the 12% 29 % 43 % workflow of physician practices? Does a physician Blackberry adopt a smartphone or an in-between computer 12% 29 % 43 %

and phone like an iPad or tablet device? All of these WinMobile are useful digital interfaces.” Dr. Ted Eytan noted 7% 29 % 43 %

that physician practices will be asking how mobility PPC can help them perform better for their patients. 6% 2 9 % 43 % If a practice is a more mature user of EHRs, he Other added, then mobility will be as much about patient 8% 29 % 43% workflow as doctor workflow. For new doctors, the transition will be smoother. Source: Epocrates survey, July 2009. Some medical schools now issue smartphones: Georgetown, The University of Louisville, and Ohio State University are among the schools that require As reimbursement models for physicians move students to use one. Today’s medical students are toward bundling and patient-centered medical “digital natives,” so using a smartphone at the point- homes, there will be greater incentives for doctors of-care comes naturally. As of July 2009, among and patients to partner in leveraging health medical students who did not have a smartphone, information technology — including smartphones. 50 percent planned to buy one within the year; Privacy and security. Keeping personally 59 percent of these planned to acquire an iPhone identifiable health information secure is a long- or iPod touch, and 21 percent planned on buying a standing challenge. The advent of mobile health Blackberry.24 See Figure 8. requires strong encryption and strong authentication. Participatory health. Patients, charged with Nonetheless, more patients are recognizing the paying more for health care and making more value of digital health records. Researchers at some clinical decisions for their and their families’ care, of Boston’s most prestigious medical institutions have begun to adopt technology-based tools to recently found that, “especially for the chronically enable deep health engagement. Most Americans and acutely ill, privacy is of far less concern to now turn to the Internet to seek health information, patients than to health professionals.”25 and at least 50 percent of Americans would like to email a physician to communicate about conditions, appointments, prescriptions, and test results. See Figure 9 on the following page.

How Smartphones Are Changing Health Care for Consumers and Providers | 15 Figure 9. Consumers Interested in Email Communication with Their Doctor, 2009

Schedule an appointment 8% 51% 44% 8%

Ask a question about a new condition 20% 38% 48% 7% • Online Chat • Doctor’s Web Site Ask a question about an existing condition • Email 20% • Text 37% 50% 8%

Update doctor on an existing condition 17% 38% % 51% 8%

Confirm an appointment 8% 45% % 53% 14%

Request a repeat Rx 10% 48% % 53% 11%

Receive test results 7% 32% % 59% 9%

None of these 73% 42% 31% 79%

Source: Consumers Would Embrace Email Communication with Their Doctor, Lightspeed Research, September 2009.

16 | California He a l t h Ca r e Fo u n d a t i o n V. Looking Forward: Insights from the Early Adoption Phase

Ult i m a t e l y , s m a r t p h o n e t e ch n o l o g y Table 2. Mobile Platforms Used for Health, 2009 is only as important as its ability to empower users Mobile Device Health Examples to communicate and collaborate in the interests Activity detector Wellcore Activity Monitor of health. The technologies are changing quickly Cell phone TellMe Networks — text message in terms of hardware platforms, software, and reminders for medication adherence (Microsoft) connectivity. New Bluetooth standards will make Messaging FrontlineSMSMedic — private, two-way phone devices for consumers cheaper and easier to platform network using open source software use in 2011. When 4G (fourth generation) wireless and cell phones devices enter the market, smartphones will further Motion sensor FitBit, Nintendo Wii mature and take on more robust functionality. Pager ALRT Technologies’ Constant Health Augmented reality software will enable smartphones Companion — prescription alert device to interact with the real world. And cell phones PDA MEDLINE Database on Tap, NLM Mobile, LabNotes will morph into smartphones as their software Mobile Personal MobiWatch M-PERS incorporates more advanced functions and adopts Emergency open source mobile operating systems such as Response System Android. The smartphone is but one platform among Senior phone Jitterbug a growing array of mobile health devices, as Table 2 Smartphone iPhone health apps — sensors for illustrates. diagnostics, such as glucose monitoring The early adoption phase of smartphone apps in Medical-specific Implantable diagnostics — including platforms patient vitals monitor, smart pills, health provides some insights for health information wearable diagnostics, wireless pillbox technology use in general, and apps in particular. Source: “Adapted from TripleTree LLC,” Wireless & Mobile Health, 2009 Low financial threshold. Smartphone apps do not require large up-front investments from health providers or consumers. There is a low barrier to entry. Apps are simple to adopt, pilot, and either an attractive “in-between” small device for health continue to use if found valuable or abandoned. This providers, but as of April 2010, it is too early to is important at a time when health providers’ access forecast. to capital is highly constrained and when return- Respect the universal platform. The White on-investment for big-dollar HIT projects is often House launched the program Text4Baby difficult to measure or too low to justify. (www.text4baby.org) in February 2010. It aims to Small is beautiful. Smartphones are about the promote maternal and child health in the United size and shape of a prescription pad, a medium that States, where the infant mortality rate ranked 30th doctors have long experience pulling out of a pocket among 31 developed countries in 2008.26 The and recording on. A desktop or laptop computer program is a public-private partnership between is far more cumbersome. The iPad may emerge as several U.S. government agencies, health care

How Smartphones Are Changing Health Care for Consumers and Providers | 17 companies, academic institutions, and virtually all good decisions at the moments they are made, from of the major telecommunications network providers, nutrition choices to shopping for healthy foods and who are waiving fees for these text messages. To move tracking steps. the needle on public health, it is important to choose Still a wireless divide for the most vulnerable. a platform that is universal. Today, that ubiquitous While cell phones are fairly ubiquitous in the U.S. platform would be cell phones and not smartphones. across socioeconomic strata, smartphones are not But in a matter of years, not decades, feature phones yet, and wireless connectivity isn’t evenly distributed, will fast morph into “smart-erphones.” For large either. B.J. Fogg observed, “If a county health health plans, health systems, and payers, smartphone department rolled something out on smartphones, health apps can be deployed in targeted population it could be discriminatory. Any agency that builds health programs. Consider Kaiser’s My Health a health program on a smartphone would battle the Manager, used by 3 million members: Even if digital divide.” Therefore, in the short term, Fogg 10 percent of Kaiser’s EHR users have smartphones, recommends that mobile health programs be built this represents 300,000 patients. for cell phones using text. “Virtually everyone has a EHRs as smartphone apps. The killer app for cell phone, and everyone can text. It’s here and now, physicians on smartphones could be electronic health if you’re going to do an intervention that reaches records adoption. One of the major announcements the masses.” When Dr. Richard Katz of the George at HIMSS 2010 was Epocrates’ development of an Washington Medical Center partnered with WellDoc iPhone- and Web-based electronic health record. on a mobile health solution for patients with One in three U.S. physicians has an Epocrates app diabetes, he found that only a handful of patients loaded on a smartphone or other handheld device. among the 700 had a smartphone with the right plan Functions might include a prescription app, an over- for the study. “This is why so much of what we do the-counter information app, or a medical calculator. with technology is home grown,” pointed out Rob According to Epocrates, the average clinician Havasy. uses one of its applications six times a day. Small The first generation of smartphone apps has physician practices already using Epocrates products yielded value for consumers and clinicians who have will probably be more receptive to adding onto their adopted them because they are agile, easy-to-use, current applications than to switch to a new, untested hand-held, and mobile. These features have not been IT partner for EHR adoption. the traditional hallmarks of health IT. They empower “My office is where I am.” Physicians’ work is providers and patients on the go. The relatively mobile, and smartphone apps can seamlessly fit into speedy disruption that apps have had on health the workflow and increase productivity, which can providers and consumers is just the beginning of a result in both opportunities for revenue enhancement “small is beautiful” phase of health care information and greater job satisfaction. technology and delivery. “My life is 24x7.” For people managing chronic Whatever comes next will undoubtedly build on health conditions such as asthma, diabetes, heart the characteristics that have made smartphones so disease, and GI issues, sound health management popular. is rooted in making good health “micro-decisions” every day. Health apps on a smartphone can bolster

18 | California He a l t h Ca r e Fo u n d a t i o n Endnotes

1. Centers for Disease Control, National Center for Health 13. Bland, E. “Cough Into Your Cell Phone, Get Diagnosis,” Statistics. “Electronic Medical Record/Electronic Health Discovery News. November 8, 2009, news.discovery.com/ Record Use by Office-based Physicians: United States, tech/cough-cell-phone-diagnosis.html. 2008 and Preliminary 2009,” December 2009. 14. Ibid. 2. ChangeWave Research. “New Survey Shows Android OS 15. Choudhri AF, et al. Handheld Device Review of Roiling the Smart Phone Market,” January 4, 2010. Abdominal CT for the Evaluation of Acute Appendicitis. 3. cnet news. “Smartphone market unfazed by recession,” RSNA 2009; Abstract SSE09-03. November 6, 2009, news.cnet.com/8301-1035_3- 16. The Accreditation Council for Continuing Medical 10392252-94.html. Education (ACCME). ACCME®Annual Report Data 2008, 4. Hein K. Phones Top List of Most-Trusted Brands. www.accme.org/dir_docs/doc_upload/1f8dc476-246a- Brandweek, October 17, 2009. Compared to other 4e8e-91d3-d24ff2f5bfec_uploaddocument.pdf. consumer goods, wireless phone manufacturers have 17. Markle Foundation. Americans Overwhelmingly Believe very loyal consumers — more loyal than any other brand Electronic Personal health Records Could Improve Their category. Among smartphones, Apple’s iPhone has the Health, June 2008. most loyal customers of any brand. In fact, six brands of mobile phones fell in the top 30 of Americans’ most 18. Chilmark Research. iPHR Market Report, February 2010. beloved brands as of September 2009. 19. Kripalani S, Xiaomei Y, Haynes RB. Interventions to 5. MobiHealthNews. “The World of Health and Medical Enhance Medication Adherence in Chronic Medical Apps,” MobiHealthNews Research Report, February 2010. Conditions. Archives of Internal Medicine. 167(6): 540 – 549. 6. Horrigan J. “Wireless Internet Use.” Pew Internet & American Life Project, July 2009. 20. Osterberg, L, Blaschke T. Adherence to Medication. New England Journal of Medicine 353:487– 497. 7. TelecomEngine. “Statistics pointing towards continuing dominance of SMS,” December 21, 2009. 21. National Consumers League. Prescription Medication Adherence Provider and Patient Perspective Final Report, 8. See note 6. June 18, 2009. 9. Gartner. “Gartner Identifies the Top 10 Consumer Mobile 22. Research in Motion. The Blackberry Report: The National Applications for 2012.” November 18, 2009, State of the Home Care Industry, October 10, 2009. www.gartner.com/it/page.jsp?id=1230413. 23. Pena, V., A.J. Watson, J.C. Kvedar, and R.W. Grant. 10. Business Wire. “One in Five Physicians Likely To Purchase “Mobile Phone Technology for Children with Type 1 and an iPad, More than 60 Percent Intrigued By New Device Type 2 Diabetes: A Parent Survey.” Journal of Diabetes According to Epocrates Survey,” February 4, 2010, Science and Technology. Volume 3, Issue 6, November 2009. www.businesswire.com/portal/site/home/permalink/?ndmview id=news_view&newsId=20100204006741&newslang=en. 24. Epocrates. 4th Annual Future Physicians of America survey, July 2009, www.epocrates.com/company/ 11 Manhattan Research. “Physicians in 2012: The Outlook mediaroom/mediaresources/surveys/4th_fpasurvey.pdf. for On Demand, Mobile, and Social Digital Media,” October 2009. 25. Walker, J., D.K. Ahern, L.X. Le, and T. Delbanco. “Insights to Internists: I Want the Computer to Know 12. Epocrates. “Brigham and Women’s Hospital Study Shows Who I Am,” Journal of General Internal Medicine, Volume Doctors are Taking Action to Improve Patient Safety and 24, Number 6, June 2009, 727– 732. Care,” December 9, 2005. www.epocrates.com/company/ news/10233.html. 26. Centers for Disease Control. “Behind International Rankings of Infant Mortality: How the United States Compares with Europe,” NCHS Data Brief, Number 23, November 2009.

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